Showing papers on "Atrial fibrillation published in 2019"
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Scott & White Hospital1, Columbia University2, Georgetown University3, Rutgers University4, Cleveland Clinic5, Laval University6, University of British Columbia7, New York University8, University of Washington9, Emory University10, Lankenau Institute for Medical Research11, University of Pennsylvania12, Morristown Medical Center13, University of London14
TL;DR: Among patients with severe aortic stenosis who were at low surgical risk, the rate of the composite of death, stroke, or rehospitalization at 1 year was significantly lower with TAVR than with surgery.
Abstract: Background Among patients with aortic stenosis who are at intermediate or high risk for death with surgery, major outcomes are similar with transcatheter aortic-valve replacement (TAVR) an...
2,917 citations
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Mayo Clinic1, Duke University2, University of Washington3, National Institutes of Health4, Cardiovascular Institute of the South5, University of Missouri6, Primary Children's Hospital7, Ruhr University Bochum8, Moscow State University9, Loyola University Chicago10, Humanitas University11, Leipzig University12, Thomas Jefferson University13, Pennsylvania State University14, Columbia University15
TL;DR: Among patients with AF, the strategy of catheter ablation, compared with medical therapy, did not significantly reduce the primary composite end point of death, disabling stroke, serious bleeding, or cardiac arrest, which should be considered in interpreting the results of the trial.
Abstract: Importance Catheter ablation is effective in restoring sinus rhythm in atrial fibrillation (AF), but its effects on long-term mortality and stroke risk are uncertain. Objective To determine whether catheter ablation is more effective than conventional medical therapy for improving outcomes in AF. Design, Setting, and Participants The Catheter Ablation vs Antiarrhythmic Drug Therapy for Atrial Fibrillation trial is an investigator-initiated, open-label, multicenter, randomized trial involving 126 centers in 10 countries. A total of 2204 symptomatic patients with AF aged 65 years and older or younger than 65 years with 1 or more risk factors for stroke were enrolled from November 2009 to April 2016, with follow-up through December 31, 2017. Interventions The catheter ablation group (n = 1108) underwent pulmonary vein isolation, with additional ablative procedures at the discretion of site investigators. The drug therapy group (n = 1096) received standard rhythm and/or rate control drugs guided by contemporaneous guidelines. Main Outcomes and Measures The primary end point was a composite of death, disabling stroke, serious bleeding, or cardiac arrest. Among 13 prespecified secondary end points, 3 are included in this report: all-cause mortality; total mortality or cardiovascular hospitalization; and AF recurrence. Results Of the 2204 patients randomized (median age, 68 years; 37.2% female; 42.9% had paroxysmal AF and 57.1% had persistent AF), 89.3% completed the trial. Of the patients assigned to catheter ablation, 1006 (90.8%) underwent the procedure. Of the patients assigned to drug therapy, 301 (27.5%) ultimately received catheter ablation. In the intention-to-treat analysis, over a median follow-up of 48.5 months, the primary end point occurred in 8.0% (n = 89) of patients in the ablation group vs 9.2% (n = 101) of patients in the drug therapy group (hazard ratio [HR], 0.86 [95% CI, 0.65-1.15];P = .30). Among the secondary end points, outcomes in the ablation group vs the drug therapy group, respectively, were 5.2% vs 6.1% for all-cause mortality (HR, 0.85 [95% CI, 0.60-1.21];P = .38), 51.7% vs 58.1% for death or cardiovascular hospitalization (HR, 0.83 [95% CI, 0.74-0.93];P = .001), and 49.9% vs 69.5% for AF recurrence (HR, 0.52 [95% CI, 0.45-0.60];P Conclusions and Relevance Among patients with AF, the strategy of catheter ablation, compared with medical therapy, did not significantly reduce the primary composite end point of death, disabling stroke, serious bleeding, or cardiac arrest. However, the estimated treatment effect of catheter ablation was affected by lower-than-expected event rates and treatment crossovers, which should be considered in interpreting the results of the trial. Trial Registration ClinicalTrials.gov Identifier:NCT00911508
864 citations
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Charité1, University of Groningen2, Cardiff University3, University of Rennes4, University of Milan5, National University of Singapore6, University of Liège7, Brigham and Women's Hospital8, Boston University9, Utrecht University10, University of Zurich11, University of Amsterdam12, University of Belgrade13, University of Cyprus14, National and Kapodistrian University of Athens15
TL;DR: A new stepwise diagnostic process, the 'HFA-PEFF diagnostic algorithm', is recommended, which requires comprehensive echocardiography and requires comprehensive natriuretic peptide levels and is typically performed by a cardiologist.
Abstract: Making a firm diagnosis of chronic heart failure with preserved ejection fraction (HFpEF) remains a challenge. We recommend a new stepwise diagnostic process, the 'HFA-PEFF diagnostic algorithm'. Step 1 (P=Pre-test assessment) is typically performed in the ambulatory setting and includes assessment for heart failure symptoms and signs, typical clinical demographics (obesity, hypertension, diabetes mellitus, elderly, atrial fibrillation), and diagnostic laboratory tests, electrocardiogram, and echocardiography. In the absence of overt non-cardiac causes of breathlessness, HFpEF can be suspected if there is a normal left ventricular (LV) ejection fraction, no significant heart valve disease or cardiac ischaemia, and at least one typical risk factor. Elevated natriuretic peptides support, but normal levels do not exclude a diagnosis of HFpEF. The second step (E: Echocardiography and Natriuretic Peptide Score) requires comprehensive echocardiography and is typically performed by a cardiologist. Measures include mitral annular early diastolic velocity (e'), LV filling pressure estimated using E/e', left atrial volume index, LV mass index, LV relative wall thickness, tricuspid regurgitation velocity, LV global longitudinal systolic strain, and serum natriuretic peptide levels. Major (2 points) and Minor (1 point) criteria were defined from these measures. A score ≥5 points implies definite HFpEF; ≤1 point makes HFpEF unlikely. An intermediate score (2-4 points) implies diagnostic uncertainty, in which case Step 3 (F1 : Functional testing) is recommended with echocardiographic or invasive haemodynamic exercise stress tests. Step 4 (F2 : Final aetiology) is recommended to establish a possible specific cause of HFpEF or alternative explanations. Further research is needed for a better classification of HFpEF.
825 citations
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TL;DR: In this paper, the authors discuss the state of the FAHA chair election process and discuss the current state of FAHA's board of directors, including the current and past chairmen.
811 citations
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Duke University1, Bristol-Myers Squibb2, University of Alberta3, University of Toronto4, Russian National Research Medical University5, Uppsala University6, National Academy of Sciences of Ukraine7, Katholieke Universiteit Leuven8, University of Sheffield9, Leipzig University10, Carol Davila University of Medicine and Pharmacy11
TL;DR: In patients with atrial fibrillation and a recent acute coronary syndrome or PCI treated with a P2Y12 inhibitor, an antithrombotic regimen that included apixaban, without aspirin, resulted in less bleeding and fewer hospitalizations without significant differences in the incidence of ischemic events than regimens that included a vitamin K antagonist, aspirin, or both.
Abstract: Background Appropriate antithrombotic regimens for patients with atrial fibrillation who have an acute coronary syndrome or have undergone percutaneous coronary intervention (PCI) are uncl...
742 citations
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TL;DR: An artificial intelligence (AI)-enabled electrocardiograph (ECG) using a convolutional neural network to detect the electrocardsiographic signature of atrial fibrillation present during normal sinus rhythm using standard 10-second, 12-lead ECGs is developed.
657 citations
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TL;DR: Among patients with symptomatic atrial fibrillation, catheter ablation, compared with medical therapy, led to clinically important and significant improvements in quality of life at 12 months.
Abstract: Importance Catheter ablation is more effective than drug therapy in restoring sinus rhythm in patients with atrial fibrillation (AF), but its incremental effect on long-term quality of life (QOL) is uncertain. Objective To determine whether catheter ablation is more beneficial than conventional drug therapy for improving QOL in patients with AF. Design, Setting, and Participants An open-label randomized clinical trial of catheter ablation vs drug therapy in 2204 symptomatic patients with AF older than 65 years or 65 years or younger with at least 1 risk factor for stroke. Patients were enrolled from November 2009 to April 2016 from 126 centers in 10 countries. Follow-up ended in December 2017. Interventions Pulmonary vein isolation, with additional ablation procedures at the discretion of the investigators, for the catheter ablation group (n = 1108) and standard rhythm and/or rate-control drugs selected and managed by investigators for the drug therapy group (n = 1096). Main Outcomes and Measures Prespecified co-primary QOL end points at 12 months, including the Atrial Fibrillation Effect on Quality of Life (AFEQT) summary score (range, 0-100; 0 indicates complete disability and 100 indicates no disability; patient-level clinically important difference, ≥5 points) and the Mayo AF-Specific Symptom Inventory (MAFSI) frequency score (range, 0-40; 0 indicates no symptoms and 40 indicates the most severe symptoms; patient-level clinically important difference, ≤−1.6 points) and severity score (range, 0-30; 0 indicates no symptoms and 30 indicates the most severe symptoms; patient-level clinically important difference, ≤−1.3 points). Results Among 2204 randomized patients (median age, 68 years; 1385 patients [63%] were men, 946 [43%] had paroxysmal AF, and 1256 [57%] had persistent AF), the median follow-up was 48.5 months, and 1968 (89%) completed the trial. The mean AFEQT summary score was more favorable in the catheter ablation group than the drug therapy group at 12 months (86.4 points vs 80.9 points) (adjusted difference, 5.3 points [95% CI, 3.7-6.9];P Conclusions and Relevance Among patients with symptomatic atrial fibrillation, catheter ablation, compared with medical therapy, led to clinically important and significant improvements in quality of life at 12 months. These findings can help guide decisions regarding management of atrial fibrillation. Trial Registration ClinicalTrials.gov Identifier:NCT00911508
335 citations
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University of British Columbia1, Montreal Heart Institute2, Laval University3, Southlake Regional Health Center4, University of Western Ontario5, Royal Jubilee Hospital6, Centre Hospitalier Universitaire de Sherbrooke7, Queen Elizabeth II Health Sciences Centre8, St. Michael's Hospital9, University of Winnipeg10
TL;DR: In this multicenter, randomized, single-blinded trial, contact-force RF ablation and two different regiments of cryoballoon ablation resulted in no difference in one-year efficacy, which was 53% by time to first recurrence but >98% burden reduction as assessed by continuous cardiac rhythm monitoring.
Abstract: Background: Advanced generation ablation technologies have been developed to achieve more effective pulmonary vein isolation (PVI) and minimize arrhythmia recurrence after atrial fibrillation (AF) ...
313 citations
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TL;DR: In first-in-human trials, pulsed field ablation preferentially affected myocardial tissue, allowing facile ultra-rapid PV isolation with excellent durability and chronic safety.
298 citations
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TL;DR: ARCADIA is the first trial to test whether anticoagulant therapy reduces stroke recurrence in patients with atrial cardiopathy but no known atrial fibrillation.
Abstract: RationaleRecent data suggest that a thrombogenic atrial substrate can cause stroke in the absence of atrial fibrillation. Such an atrial cardiopathy may explain some proportion of cryptogenic strok...
280 citations
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TL;DR: Postoperative atrial fibrillation (POAF) complicates 20–40% of cardiac surgical procedures and 10–20% of non-cardiac thoracic operations, and can be prevented by targeting autonomic alterations and inflammation.
Abstract: Postoperative atrial fibrillation (POAF) complicates 20-40% of cardiac surgical procedures and 10-20% of non-cardiac thoracic operations. Typical features include onset at 2-4 days postoperatively, episodes that are often fleeting and a self-limited time course. Associated adverse consequences of POAF include haemodynamic instability, increased risk of stroke, lengthened hospital and intensive care unit stays and greater costs. Underlying mechanisms are incompletely defined but include intraoperative and postoperative phenomena, such as inflammation, sympathetic activation and cardiac ischaemia, that combine to trigger atrial fibrillation, often in the presence of pre-existing factors, making the atria vulnerable to atrial fibrillation induction and maintenance. A better understanding of the underlying mechanisms might enable the identification of new therapeutic targets. POAF can be prevented by targeting autonomic alterations and inflammation. β-Blocker prophylaxis is the best-established preventive therapy and should be started or continued before cardiac surgery, unless contraindicated. When POAF occurs, rate control usually suffices, and routine rhythm control is unnecessary; rhythm control should be reserved for patients who develop haemodynamic instability or show other indications that rate control alone will be insufficient. In this Review, we summarize the epidemiological and clinical features of POAF, the available pathophysiological evidence from clinical and experimental investigations, the results of prophylactic and therapeutic approaches and the consensus recommendations of various national and international societies.
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TL;DR: As antithrombotic therapy, rivaroxaban monotherapy was noninferior to combination therapy for efficacy and superior for safety in patients with atrial fibrillation and stable coronary artery disease.
Abstract: Background There are limited data from randomized trials evaluating the use of antithrombotic therapy in patients with atrial fibrillation and stable coronary artery disease. Methods In a ...
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TL;DR: This review summarizes the prevalence and prognostic importance of atrial functional MR, providing mechanistic insights compared with those of secondary MR and suggesting potential therapeutic targets.
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TL;DR: In this large cohort of patients with HFrEF, FTR was common and independently associated with PHTN, atrial-fibrillation and more severe heart failure presentation, and clinical trials should be directed at testing FTR treatment.
Abstract: Background: Functional tricuspid regurgitation (FTR) is common in heart failure with reduced ejection fraction and mostly consequent to pulmonary hypertension. However, the intrinsic clinical impli...
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TL;DR: A practical clinical approach to the evaluation and management of known or suspected OSA in patients with CVD consisting of recommendations integrated from several separate societal practice guidelines combined with several of their own suggestions on issues not addressed by current guidelines, based on their own clinical experience and best available literature.
Abstract: Cardiovascular disease (CVD) remains a highly prevalent cause of morbidity and mortality, both in the United States and worldwide. In parallel with the development of new and improved therapies for established CVD such as coronary artery disease or heart failure (HF), there has been an increased focus on modification of cardiovascular risk factors for both primary and secondary prevention, reflecting an evolving understanding of CVD as a systemic process with numerous determinants.
Obstructive sleep apnea (OSA) has been associated with many different forms of CVD including hypertension, stroke, HF, coronary artery disease, and atrial fibrillation (AF).1 Adults with OSA not only have an increased risk of developing comorbid CVD but also have worse outcomes related to CVD. OSA is highly prevalent, estimated to affect 34% of men and 17% of women in the general population2 and 40% to 60% of patients with CVD.3, 4 Furthermore, the prevalence is increasing, with these figures representing a 30% increase over the previous 2 decades,2 likely related to the obesity epidemic as well as an aging population.
Despite the clear association between CVD and OSA, randomized trials have failed to demonstrate that treatment of sleep apnea improves hard cardiovascular outcomes in patients with established CVD.5 Nevertheless, this area remains controversial, as randomized trials performed to date remain limited in number as well as design, highlighting the need for further study.6 Furthermore, the current literature suggests that the impact of diagnosing and treating OSA varies between specific CVD processes, implying the need for a more sophisticated understanding and nuanced clinical approach to this issue. In this article we review the literature pertaining to OSA in patients with CVD. Additionally, we offer a practical clinical approach to the evaluation and management of known or suspected OSA in patients with CVD consisting of recommendations integrated from several separate societal practice guidelines combined with several of our own suggestions on issues not addressed by current guidelines, based on our own clinical experience and best available literature.
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TL;DR: The complex interaction between diabetes and AF is reviewed, and its effect on the prevention and treatment of AF is explored.
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TL;DR: Right ventricular structure and function deteriorate to greater extent over time when compared with changes in the left ventricle, and interventions targeting modifiable risk factors identified for incident RVD can prevent RVD and thus improve outcomes.
Abstract: AIMS Prevalent right ventricular (RV) dysfunction (RVD) is associated with increased mortality in patients with heart failure with preserved ejection fraction (HFpEF), but no study has characterized long-term changes in RV structure and function within the same patient. METHODS AND RESULTS Patients with unequivocal HFpEF defined by either invasive haemodynamics or hospitalization for pulmonary oedema (n = 271) underwent serial echocardiographic evaluations >6 months apart. Clinical, structural, functional, and haemodynamic characteristics were examined. Over a median of 4.0 years (interquartile range 2.1-6.1), there was a 10% decline in RV fractional area change and 21% increase in RV diastolic area (both P < 0.0001). These changes greatly exceeded corresponding changes in the left ventricle. The prevalence of tricuspid regurgitation increased by 45%. Of 238 patients with normal RV function at Exam 1, 55 (23%) developed RVD during follow-up. Development of RVD was associated with both prevalent and incident atrial fibrillation (AF), higher body weight, coronary disease, higher pulmonary artery and left ventricular filling pressures, and RV dilation. Patients with HFpEF developing incident RVD had nearly two-fold increased risk of death (adjusted hazard ratio 1.89, 95% confidence interval 1.01-3.44; P = 0.04). CONCLUSION While previous attention has centred on the left ventricle in HFpEF, these data show that right ventricular structure and function deteriorate to greater extent over time when compared with changes in the left ventricle. Further study is required to evaluate whether interventions targeting modifiable risk factors identified for incident RVD, including abnormal haemodynamics, AF, coronary disease, and obesity, can prevent RVD and thus improve outcomes.
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TL;DR: Improvement in quality of life at 12 months was greater for those treated with catheter ablation compared with antiarrhythmic medication, although the study was limited by absence of blinding.
Abstract: Importance Quality of life is not a standard primary outcome in ablation trials, even though symptoms drive the indication. Objective To assess quality of life with catheter ablation vs antiarrhythmic medication at 12 months in patients with atrial fibrillation. Design, Setting, and Participants Randomized clinical trial at 4 university hospitals in Sweden and 1 in Finland of 155 patients aged 30-70 years with more than 6 months of atrial fibrillation and treatment failure with 1 antiarrhythmic drug or β-blocker, with 4-year follow-up. Study dates were July 2008–September 2017. Major exclusions were ejection fraction 60 mm, ventricular pacing dependency, and previous ablation. Interventions Pulmonary vein isolation ablation (n = 79) or previously untested antiarrhythmic drugs (n = 76). Main Outcomes and Measures Primary outcome was the General Health subscale score (Medical Outcomes Study 36-Item Short-Form Health Survey) at baseline and 12 months, assessed unblinded (range, 0 [worst] to 100 [best]). There were 26 secondary outcomes, including atrial fibrillation burden (% of time) from baseline to 12 months, measured by implantable cardiac monitors. The first 3 months were excluded from rhythm analysis. Results Among 155 randomized patients (mean age, 56.1 years; 22.6% women), 97% completed the trial. Of 79 patients randomized to receive ablation, 75 underwent ablation, including 2 who crossed over to medication and 14 who underwent repeated ablation procedures. Of 76 patients randomized to receive antiarrhythmic medication, 74 received it, including 8 who crossed over to ablation and 43 for whom the first drug used failed. General Health score increased from 61.8 to 73.9 points in the ablation group vs 62.7 to 65.4 points in the medication group (between-group difference, 8.9 points; 95% CI, 3.1-14.7;P = .003). Of 26 secondary end points, 5 were analyzed; 2 were null and 2 were statistically significant, including decrease in atrial fibrillation burden (from 24.9% to 5.5% in the ablation group vs 23.3% to 11.5% in the medication group; difference –6.8% [95% CI, –12.9% to –0.7%];P = .03). Of the Health Survey subscales, 5 of 7 improved significantly. Most common adverse events were urosepsis (5.1%) in the ablation group and atrial tachycardia (3.9%) in the medication group. Conclusions and Relevance Among patients with symptomatic atrial fibrillation despite use of antiarrhythmic medication, the improvement in quality of life at 12 months was greater for those treated with catheter ablation compared with antiarrhythmic medication. Although the study was limited by absence of blinding, catheter ablation may offer an advantage for quality of life. Trial Registration clinicaltrialsregister.eu Identifier:2008-001384-11
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McMaster University1, University of Sydney2, University of Modena and Reggio Emilia3, Odense University Hospital4, British Heart Foundation5, Maastricht University6, Charité7, Lund University8, François Rabelais University9, Karolinska Institutet10, Sunnybrook Health Sciences Centre11, Hackensack University Medical Center12, Tokai University13, University of Western Australia14, Trinity College, Dublin15, University of Oxford16, Cornell University17, University of Birmingham18, Imperial College London19, University of Liverpool20, University Hospital of North Norway21, Edinburgh Napier University22, RMIT University23, Duke University24, University of Belgrade25, University of Glasgow26, Columbia University27, Universidade Federal de Minas Gerais28, Ludwig Maximilian University of Munich29, University of Copenhagen30, University of Göttingen31, University of Melbourne32, Royal Melbourne Hospital33
TL;DR: Clinically diagnosed AF after a stroke or a transient ischemic attack is associated with significantly increased risk of recurrent stroke or systemic embolism, in particular, with additional stroke risk factors, and requires OAC rather than antiplatelet therapy.
Abstract: Cardiac thromboembolism attributed to atrial fibrillation (AF) is responsible for up to one-third of ischemic strokes. Stroke may be the first manifestation of previously undetected AF. Given the efficacy of oral anticoagulants in preventing AF-related ischemic strokes, strategies of searching for AF after a stroke using ECG monitoring followed by oral anticoagulation (OAC) treatment have been proposed to prevent recurrent cardioembolic strokes. This white paper by experts from the AF-SCREEN International Collaboration summarizes existing evidence and knowledge gaps on searching for AF after a stroke by using ECG monitoring. New AF can be detected by routine plus intensive ECG monitoring in approximately one-quarter of patients with ischemic stroke. It may be causal, a bystander, or neurogenically induced by the stroke. AF after a stroke is a risk factor for thromboembolism and a strong marker for atrial myopathy. After acute ischemic stroke, patients should undergo 72 hours of electrocardiographic monitoring to detect AF. The diagnosis requires an ECG of sufficient quality for confirmation by a health professional with ECG rhythm expertise. AF detection rate is a function of monitoring duration and quality of analysis, AF episode definition, interval from stroke to monitoring commencement, and patient characteristics including old age, certain ECG alterations, and stroke type. Markers of atrial myopathy (eg, imaging, atrial ectopy, natriuretic peptides) may increase AF yield from monitoring and could be used to guide patient selection for more intensive/prolonged poststroke ECG monitoring. Atrial myopathy without detected AF is not currently sufficient to initiate OAC. The concept of embolic stroke of unknown source is not proven to identify patients who have had a stroke benefitting from empiric OAC treatment. However, some embolic stroke of unknown source subgroups (eg, advanced age, atrial enlargement) might benefit more from non-vitamin K-dependent OAC therapy than aspirin. Fulfilling embolic stroke of unknown source criteria is an indication neither for empiric non-vitamin K-dependent OAC treatment nor for withholding prolonged ECG monitoring for AF. Clinically diagnosed AF after a stroke or a transient ischemic attack is associated with significantly increased risk of recurrent stroke or systemic embolism, in particular, with additional stroke risk factors, and requires OAC rather than antiplatelet therapy. The minimum subclinical AF duration required on ECG monitoring poststroke/transient ischemic attack to recommend OAC therapy is debated.
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TL;DR: During the complete 2-year follow-up of Evaluating Real-Life Clinical Outcomes in Atrial Fibrillation Patients Receiving the WATCHMAN Left Atrial Appendage Closure Technology, patients with a WATCHMAN left atrial appendage occlusion device had consistently low rates of stroke and nonprocedural bleeding, although most were contraindicated to oral anticoagulation and used only single antiplatelet therapy or nothing.
Abstract: Background: Left atrial appendage occlusion with WATCHMAN has emerged as viable alternative to vitamin K antagonists in randomized controlled trials. Evaluating real-life clinical outcomes in atria...
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TL;DR: The concept of pacing the conduction system distal to the His bundle to bypass the region of conduction block was proposed and the procedural feasibility of left bundle branch pacing was demonstrated.
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TL;DR: Personalized computational modelling can reliably predetermine ablation targets in patients with persistent atrial fibrillation and atrial fibrosis, and could improve the accuracy and efficacy of targeted AF ablation in patients while eliminating the need for repeat procedures.
Abstract: Atrial fibrillation (AF)-the most common arrhythmia-significantly increases the risk of stroke and heart failure. Although catheter ablation can restore normal heart rhythms, patients with persistent AF who develop atrial fibrosis often undergo multiple failed ablations, and thus increased procedural risks. Here, we present personalized computational modelling for the reliable predetermination of ablation targets, which are then used to guide the ablation procedure in patients with persistent AF and atrial fibrosis. First, we show that a computational model of the atria of patients identifies fibrotic tissue that, if ablated, will not sustain AF. Then, we report the results of integrating the target ablation sites in a clinical mapping system and testing its feasibility in ten patients with persistent AF. The computational prediction of ablation targets avoids lengthy electrical mapping and could improve the accuracy and efficacy of targeted AF ablation in patients while eliminating the need for repeat procedures.
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TL;DR: There is an interaction between AF duration and CHA2DS2-VASc score which can further risk stratify AF patients for SSE and may be useful in guiding anticoagulation therapy.
Abstract: Background: Studies of patients with cardiovascular implantable electronic devices show a relationship between atrial fibrillation (AF) duration and stroke risk, although the interaction with CHA2D...
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University of Groningen1, University of Amsterdam2, National Institutes of Health3, Stavanger University Hospital4, Athens State University5, National and Kapodistrian University of Athens6, University of Dundee7, University of Brescia8, University of Leicester9, Glenfield Hospital10, Wrocław Medical University11, French Institute of Health and Medical Research12
TL;DR: Little is known regarding the association between IL‐6 and clinical characteristics, outcomes and other inflammatory biomarkers in HF, and this work aimed to identify and characterize these associations.
Abstract: Aims:
Inflammation is a central process in the pathophysiology of heart failure (HF), but trials targeting tumour necrosis factor (TNF)‐α were largely unsuccessful. Interleukin (IL)‐6 is an important inflammatory mediator and might constitute a potential pharmacologic target in HF. However, little is known regarding the association between IL‐6 and clinical characteristics, outcomes and other inflammatory biomarkers in HF. We thus aimed to identify and characterize these associations.
Methods and results:
Interleukin‐6 was measured in 2329 patients [89.4% with a left ventricular ejection fraction (LVEF) ≤ 40%] of the BIOSTAT‐CHF cohort. The primary outcome was all‐cause mortality and HF hospitalization during 2 years, with all‐cause, cardiovascular (CV), and non‐CV death as secondary outcomes. Approximately half (56%) of all included patients had plasma IL‐6 values greater than the previously determined 95th percentile of normal values at baseline. Elevated N‐terminal pro‐brain natriuretic peptide, procalcitonin and hepcidin, younger age, TNF‐α/IL‐1‐related biomarkers, or having iron deficiency, atrial fibrillation and LVEF > 40% independently predicted elevated IL‐6 levels. IL‐6 independently predicted the primary outcome [HR (95% confidence interval) per doubling: 1.16 (1.11–1.21), P < 0.001], all‐cause mortality [1.22 (1.16–1.29), P < 0.001] and CV as well as non‐CV mortality [1.16 (1.09–1.24), P < 0.001; 1.31 (1.18–1.45), P < 0.001], but did not improve discrimination in previously published risk models.
Conclusions:
In a large, heterogeneous cohort of HF patients, elevated IL‐6 levels were found in more than 50% of patients and were associated with iron deficiency, reduced LVEF, atrial fibrillation and poorer clinical outcomes. These findings warrant further investigation of IL‐6 as a potential therapeutic target in specific HF subpopulations.
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TL;DR: An AFSW is highly sensitive for detection of AF and assessment of AF duration in an ambulatory population when compared with an ICM, and such devices may represent an inexpensive, noninvasive approach to long-term AF surveillance and management.
Abstract: Background: Atrial fibrillation (AF) burden and duration appear to be related to stroke risk. A wearable consumer electronic device could provide long-term assessment of these measures inexpensivel...
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TL;DR: Adequately powered randomised controlled trials comparing early to later oral anticoagulation with DOACs in ischaemic stroke associated with atrial fibrillation are justified to confirm the acceptable safety and efficacy of this strategy.
Abstract: BACKGROUND: About 13-26% of all acute ischaemic strokes are related to non-valvular atrial fibrillation, the most common cardiac arrhythmia globally. Deciding when to initiate oral anticoagulation in patients with non-valvular atrial fibrillation is a longstanding, common, and unresolved clinical challenge. Although the risk of early recurrent ischaemic stroke is high in this population, early oral anticoagulation is suspected to increase the risk of potentially harmful intracranial haemorrhage, including haemorrhagic transformation of the infarct. This assumption, and current treatment guidelines, are based on historical, mostly observational data from patients with ischaemic stroke and atrial fibrillation treated with heparins, heparinoids, or vitamin K antagonists (VKAs) to prevent recurrent ischaemic stroke. Randomised controlled trials have subsequently shown that direct oral anticoagulants (DOACs; ie, apixaban, dabigatran, edoxaban, and rivaroxaban) are at least as effective as VKAs in primary and secondary prevention of atrial fibrillation-related ischaemic stroke, with around half the risk of intracranial haemorrhage. However, none of these DOAC trials included patients who had experienced ischaemic stroke recently (within the first few weeks). Clinicians therefore remain uncertain regarding when to commence DOAC administration after acute ischaemic stroke in patients with atrial fibrillation. RECENT DEVELOPMENTS: Prospective observational studies and two small randomised trials have investigated the risks and benefits of early DOAC-administration initiation (most with a median delay of 3-5 days) in mild-to-moderate atrial fibrillation-associated ischaemic stroke. These studies reported that early DOAC treatment was associated with a low frequency of clinically symptomatic intracranial haemorrhage or surrogate haemorrhagic lesions on MRI scans, whereas later DOAC-administration initiation (ie, >7 days or >14 days after index stroke) was associated with an increased frequency of recurrent ischaemic stroke. WHERE NEXT?: Adequately powered randomised controlled trials comparing early to later oral anticoagulation with DOACs in ischaemic stroke associated with atrial fibrillation are justified to confirm the acceptable safety and efficacy of this strategy. Four such randomised controlled trials (collectively planned to include around 9000 participants) are underway, either using single cutoff timepoints for early versus late DOAC-administration initiation, or selecting DOAC-administration timing according to the severity and imaging features of the ischaemic stroke. The results of these trials should help to establish the optimal timing to initiate DOAC administration after recent ischaemic stroke and whether the timing should differ according to stroke severity. Results of these trials are expected from 2021.
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Population Health Research Institute1, University of Toronto2, Sunnybrook Health Sciences Centre3, University Hospital of Basel4, Bayer5, University of Pennsylvania6, Masaryk University7, Sapienza University of Rome8, University of Western Australia9, University of Alberta10, Oregon Health & Science University11, Capital Medical University12, International University of Health and Welfare13, Charité14, Foothills Medical Centre15, Medical University of Warsaw16, University of Coimbra17
TL;DR: Rivaroxaban was associated with a reduced risk of recurrent stroke among patients with ESUS and moderate or severe left atrial enlargement; however, this needs to be independently confirmed before influencing clinical practice.
Abstract: Importance The NAVIGATE ESUS randomized clinical trial found that 15 mg of rivaroxaban per day does not reduce stroke compared with aspirin in patients with embolic stroke of undetermined source (ESUS); however, it substantially reduces stroke risk in patients with atrial fibrillation (AF). Objective To analyze whether rivaroxaban is associated with a reduction of recurrent stroke among patients with ESUS who have an increased risk of AF. Design, Setting, and Participants Participants were stratified by predictors of AF, including left atrial diameter, frequency of premature atrial contractions, and HAVOC score, a validated scheme using clinical features. Treatment interactions with these predictors were assessed. Participants were enrolled between December 2014 and September 2017, and analysis began March 2018. Intervention Rivaroxaban treatment vs aspirin. Main Outcomes and Measures Risk of ischemic stroke. Results Among 7112 patients with a mean (SD) age of 67 (9.8) years, the mean (SD) HAVOC score was 2.6 (1.8), the mean (SD) left atrial diameter was 3.8 (1.4) cm (n = 4022), and the median (interquartile range) daily frequency of premature atrial contractions was 48 (13-222). Detection of AF during follow-up increased for each tertile of HAVOC score: 2.3% (score, 0-2), 3.0% (score, 3), and 5.8% (score, >3); however, neither tertiles of the HAVOC score nor premature atrial contractions frequency impacted the association of rivaroxaban with recurrent ischemic stroke (P for interaction = .67 and .96, respectively). Atrial fibrillation annual incidence increased for each tertile of left atrial diameter (2.0%, 3.6%, and 5.2%) and for each tertile of premature atrial contractions frequency (1.3%, 2.9%, and 7.0%). Among the predefined subgroup of patients with a left atrial diameter of more than 4.6 cm (9% of overall population), the risk of ischemic stroke was lower among the rivaroxaban group (1.7% per year) compared with the aspirin group (6.5% per year) (hazard ratio, 0.26; 95% CI, 0.07-0.94;Pfor interaction = .02). Conclusions and Relevance The HAVOC score, left atrial diameter, and premature atrial contraction frequency predicted subsequent clinical AF. Rivaroxaban was associated with a reduced risk of recurrent stroke among patients with ESUS and moderate or severe left atrial enlargement; however, this needs to be independently confirmed before influencing clinical practice.
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TL;DR: New-onset POAF is associated with an increased risk of stroke and mortality, both in the short-term and long-term, and the best strategy to reduce stroke risk among patients needs to be determined.
Abstract: Background and Purpose— Although believed to be transient and self-limiting, new-onset perioperative/postoperative atrial fibrillation (POAF) might be a risk factor for stroke and mortality. We con...
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TL;DR: Patients with CA undergoing DCCV had a significantly high cancellation rate mainly due to a high incidence of intracardiac thrombus even among patients who received adequate anticoagulation, although the success rate of restoring sinus rhythm was high, tachyarrhythmias and bradyarrh Rhythm were significantly more frequent in CA patients compared with control patients.
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TL;DR: A number of retrospective observational and prospective studies support that anticoagulation in patients with AF may reduce the risk of cognitive decline and dementia, but it still remains unproven if antICOagulation reduces cognitive decline or dementia in AF patients based on randomized trials.